Sunshine Act May Reduce Patient Trust in Physicians

Kerry Dooley Young

April 16, 2019

Public disclosure of industry payments to the medical community may erode patients' trust in physicians, regardless of whether individual physicians accept financial support from drug and device companies, according to the authors of a newly published study.

"An unintended consequence of the public disclosure of industry payments via Open Payments may have been diminished trust among American individuals in their physicians," write Genevieve P. Kanter, PhD, of the University of Pennsylvania, Philadelphia, and colleagues in an article published online April 12 in JAMA Network Open.

In a survey of 1388 US adults conducted before and after the launch of the federal Open Payments database, the authors found a 2.7% decline in trust in one's own physician, as assessed using the validated Wake Forest measure of trust.

Yet, the authors note, many survey respondents' physicians had not received industry payments.

"Therefore, public disclosure may have resulted in negative reputational spillovers affecting 'pharma-free' physicians and physicians with industry ties," Kanter and colleagues write.

The Physician Payments Sunshine Act, which was included in the 2010 Patient Protection and Affordable Care Act, mandated the creation of the publicly accessible Open Payments database.

The database, which is maintained by the Centers for Medicare & Medicaid Services, tracks payments to physicians and ownership stakes that physicians hold in medical device firms and pharmaceutical companies. It also gives an accounting of food and beverage and travel costs paid by these companies.

To monitor the effects of these disclosures on public trust in physicians, Kanter and colleagues examined the results of two rounds of surveys.

The first wave was conducted from September 26 to October 3, 2014. Of those surveys, 90.5% were completed before September 30, the date on which the Open Payments data were released. The second wave was conducted from September 16 to October 2, 2016.

In the current analysis, the authors focused on respondents who reported seeing the same physician in both the first and second waves. In addition to the decline in trust in one's own physician, the researchers found a 2.2% decline in trust in the medical profession as a whole.

In an invited commentary in JAMA Network Open about the article by Kanter and colleagues, Kathryn R. Tringale, MD, MAS, of Kaiser Permanente Southern California, Los Angeles, and Jona A. Hattangadi-Gluth, MD, of the University of California, San Diego, note that "major assumptions" would be required in order to attribute a decline in patient trust to the establishment of the Open Payments database.

"First, we would have to assume that respondents even know that Open Payments exists; however, prior research shows that only 12% of US adults are aware of the data," they write.

In addition, "frustrations with insurance coverage, availability of physicians, access to care, media coverage of health care, and publicized physician scandals" may have played a role in a decline in trust in the period studied by Kanter and colleagues.

"Interesting Plot Twist"

Tringale and Hattangadi-Gluth do note what they called "an interesting plot twist" in the study by Kanter and colleagues.

Only 3% of respondents in the study reported knowing whether their physician had received industry payments, Tringale and Hattangadi-Gluth note. But in this group, trust in their physician increased for those respondents who knew that his or her physician had not receive payments, as did trust in the medical profession as a whole, regardless of whether their physician had received industry payments, Tringale and Hattangadi-Gluth write.

The commentators indicate that there could be selection bias in this small group, because its members may have had their regular physicians in mind when researching financial ties. If these physicians were in the primary care field, this set of survey respondents thus may have been "pleasantly surprised" by the relatively small payments made to their physicians, Tringale and Hattangadi-Gluth write.

"Or, perhaps this distinct subset of more trusting respondents reflects the important role of interacting with the data and developing one's own opinion to achieve the true 'transparency' that promotes trust," write Tringale and Hattangadi-Gluth, who have conducted a study on financial ties between physicians and industry groups.

The study by Kanter and colleagues should trigger a deeper examination of "the notion that public disclosure equates to transparency and that this transparency is enough to guarantee patient trust," Tringale and Hattangadi-Gluth emphasize. They note that developing trust goes beyond just releasing data; it requires discussions between patients and physicians.

"We can thank the implementation of Open Payments for starting the conversation, but it is up to us now to continue an honest, face-to-face discussion with our patients if we want to earn and maintain their trust," Tringale and Hattangadi-Gluth write.

For their part, Kanter and colleagues call for greater sensitivity to the effects of disclosure of information about payments to physicians.

"Much of the media coverage of Open Payments has focused on the large amount of industry money directed toward physicians overall and on very large payments received by a minority of physicians," Kanter and colleagues write. "The critical tone of news media investigations using Open Payments data may have generated a sense of alarm rather than reassurance among patients."

The authors also suggest approaches to reduce "spillover consequences" from disclosure of industry ties. For example, physicians who have no industry ties could take the initiative by informing current and prospective patients of that fact.

"Policymakers, journalists, and scholars should also take care to set their discussions of physicians who receive very high payments in the context of the broader population of physicians," Kanter and colleagues continue. "Patients should understand that such cases are not the norm: the median annual payment to physicians was $201 in the 2015 Open Payments data."

The study was supported by the Greenwall Foundation. The authors have disclosed no relevant financial relationships. Tringale has received grants from the National Institutes of Health unrelated to the commentary. Hattangadi-Gluth has received grants from Varian Medical, Systems, and Vision RT for work outside of the commentary.

JAMA Network Open. Published online April 12, 2019. Full text, Commentary

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